On March 10, 2015, a federal Appeals Court ruled against CIGNA for out-of-network provider’s ERISA right to sue and out-of-network patient’s rights to both ERISA discount and PPO discount. In a consistent holding with a recent Ninth Circuit decision on November 5, 2014 for out-of-network provider’s ERISA right to sue, for the first time, the 5th Circuit provides very specific step-by-step ERISA legal guidelines to determine whether all ERISA plans condition full coverage on collection of full deductible and coinsurance, and whether CIGNA violated federal ERISA law in its inconsistent or discriminative out-of-network practice compared to its in-network practice in its ERISA plan administration. ERISAclaim.com demystifies this final comprehensive court victory for all out-of-network patients and providers.

On March 11, 2015, ERISAclaim.com announced new ERISA Out-Of-Network Claims Specialist training programs strictly in accordance with this most comprehensive federal appellate court decision, which states: “There are strong arguments that Cigna’s plan interpretation is not “legally correct,” in which case the inquiry proceeds to determine whether Cigna nonetheless had discretion to interpret the plan as it did. On a finding that the plans, read correctly, do not condition coverage on collection of coinsurance, the question would be whether Cigna nevertheless had discretion to absolve itself of responsibility for payment of the greater part of thousands of claims…” according to court documents.

“For millions of out-of-network ERISA plan participants and beneficiaries, a federal appeals court ruled that out-of-network ERISA discount must be treated consistently as in-network PPO discount in deductible collection under ERISA. This ERISA landmark decision may save millions of Americans from medical bankruptcies”, says Dr. Jin Zhou, president of ERISAclaim.com, a national expert on ERISA appeals and compliance.

In this CIGNA case, an out-of-network hospital provider was denied by CIGNA for a part of or all medical claims unless the patient’s full deductible and coinsurance were collected or billed for by the hospital. The Fifth Circuit ruled for the hospital’s ERISA right to sue and outlined legal steps under ERISA to determine if an ERISA plan truly requires full deductible collection and balance billing:

“Cigna argues that if we find standing we ought nonetheless to affirm the grant of summary judgment against North Cypress’s benefit underpayment claims on the merits; that its reading of the plan language was “legally correct” or otherwise within its discretion, and that its actions rested on “substantial evidence.”57 …. The “most important factor to consider” in the legal correctness inquiry is whether Cigna’s “interpretation is consistent with a fair reading of the plan[s],” according to court documents.

The court explains whether CIGNA violated ERISA: “The inquiry is thus whether ordinary plan members who read that “payment for the following is specifically excluded from this plan: . . . charges for which you are not obligated to pay or for which you are not billed,” would understand that they have no insurance coverage if they are not charged for coinsurance. That is, would a plan member understand the language to condition coverage on the collection of coinsurance, rather than simply describing the fact that the insurance does not cover all of a patient’s costs…..There are strong arguments that Cigna’s plan interpretation is not ‘legally correct,’ in which case the inquiry proceeds to determine whether Cigna nonetheless had discretion to interpret the plan as it did,” according to court documents.

Finally, the court rejected CIGNA’s full deductible and coinsurance collection or no coverage argument, and explained that an out-of-network patient has same ERISA rights as an in-network patient for deductible and coinsurance obligations under ERISA plans:

“Also relevant is whether Cigna denied all coverage to patients who were not charged or “billed” for their copays or coinsurance by in-network providers,” according to court documents.

To find out more about PPACA Claims and Appeals Compliance Services from ERISAclaim.com:

Located in a Chicago suburb in Illinois, for over 15 years, ERISAclaim.com is the only ERISA & PPACA consulting, publishing and website resource for healthcare providers in the country. ERISAclaim.com offers free webinars, basic and advanced educational seminars and on-site claims specialist certification programs for doctors, hospitals and commercial companies, as well as numerous pending national ERISA class action litigation support. Dr. Jin Zhou is regarded as the industry “Godfather of ERISA claims” for healthcare providers.

For any questions, please contact Dr. Jin Zhou, president of ERISAclaim.com, at 630-808-7237.